What Are the Indications For Spinal Discectomy Surgery With a Lumbar Herniated Disc (Slipped Disc)?

The incidence of having a lumbar herniated disc (slipped disc) with resultant sciatica in the US is 1%. So it's a common phenomenon and a considerable source of pain and disability when the pinched nerve happens.

Does it mean a patient always needs surgery for pain relief? The answer is no. The vast majority of patients with a lumbar herniated disc (slipped disc) achieve pain resolution without having a spinal laminectomy surgery.

Once the diagnosis of lumbar herniated disc is made, conservative treatment should begin. Pain management for the lumbar disk herniation can include physical therapy, spinal decompression treatment, chiropractic treatment, spinal epidural injections, and pain medications including NSAIDS, Tylenol, Narcotics, Muscel Relaxants, or neuropathic modulation medications. In the very acute phase, a medrol dose pak may be extremely beneficial which is a large initial dose of Prednisone (steroid) which tapers off over a few days.

If a patient is simply experiencing sciatica pain from the herniated disk, a decision for surgery turns into a quality of life decision. If the radicular pain from the pinched disk is unbearable after 6 weeks or more, textbooks consider spinal discectomy surgery to be indicated. Studies have shown the results of laminectomy surgery for lumbar disc herniations to be extremely effective. When those results are compared to conservative treatment for a lumbar herniated disc at one year, the results are equivalent. So if the patient can stand the sciatica pain until it resolves, he or she can avoid the risks of surgery.

If the patient begins to have a neurologic deficit from the "slipped disc" then the situation changes. This may include a foot drop if the patient has an L4-L5 herniated disc impinging on the L5 nerve root, or possible quadriceps weakness if the patient has an L3-L4 herniation. A neurologic deficit that is increasing and causing more weakness is a clear indication for lumbar discectomy surgery. If the neurologic deficit is stagnant, the situation can be monitored for a few months. However, it is unclear whether or not if decompression surgery is performed the neurologic deficit will reverse the longer one waits. Patients need to be informed of this.

If a patient with a lumbar herniated disk experiences bowel or bladder problems he or she should be instructed that it is a surgical emergency. That could be a condition called cauda equina syndrome and needs to be addressed immediately.

To summarize, most lumbar herniated disc conditions are best treated non-operatively with conservative pain management treatment including physical therapy, chiropractic treatment, spinal decompression, spinal epidural injections, and pain medications. If 6 weeks or more goes by and the sciatica pain from the pinched nerve is unbearable, spinal laminectomy and discectomy surgery is indicated. Increasing neurologic deficit is a clear indication for discectomy surgery and bowel or bladder insufficiency is a surgical emergency.